Maternal Death and the United States {Birth Without Fear}

by Birth Without Fear on February 20, 2014

Maternal Death – the death of a woman while pregnant or within 42 days of termination of pregnancy, irrespective of the duration and site of the pregnancy, from any cause related to or aggravated by the pregnancy or its management but not from accidental or incidental causes. (WHO)

This is a subject no one really wants to talk about. Mothers die. Mothers die in pregnancy and childbirth and just after birth. The weight of that reality is just so heavy and heart breaking. In our current birth culture, fear reigns. However, fear reigns without reason or knowledge of what really needs fear. And of course – all of us hope to Birth Without Fear. And so, I approach this subject with a heavy heart but hope as well.

Where Does It Happen?

In short, it happens everywhere. However, some areas are more prone than others. This can be due to lack of care – think of sub-Saharan Africa or rural villages in some undeveloped countries. Maternal death in those areas is an unfortunate fact of life (though organizations are striving to change this).

But apart from the “obvious” places, where do you suppose it happens? Perhaps war-stricken places, or those places without advanced medical facilities? Would it surprise you to know that the United States has one of the highest maternal mortality rates in the developed world?

Yes – you read that right. Our current maternal mortality rate is 21 deaths per 100,000 live births as of 2010 (WHO). This rate went up from 2005 (18/100,000). The 2010 “Healthy People” Goal for the United States was set at 4.3/100,000 – we grievously missed that by a large margin. The 2020 goal is 11.4/100,000, which would only be a 10% decrease from what the US considers to be its current statistic (the 12.7/100,000). I find it interesting that the government decided after they missed the 2010 goal that maybe they should try less to save mothers, since their efforts before had no effect and saw a rise in deaths.

The WHO number is adjusted from the number reported by the CDC (12.7/100,000) – this is because the United States does not have a universal system of reporting maternal deaths and the CDC admits that our numbers are drastically under reported due to this lack of uniformity in reporting (See this CDC publication, specifically page 20). Currently, only 25 states make it mandatory to state that a death was pregnancy related on the death certificate – and even this method is questionable due to lack of doctor training in filling out certificates and the great fear of litigation in the medical system. Ina May Gaskin writes about the lack of reporting here.

Other countries have much better standards of reporting. The “gold standard” is considered to the be reporting system in place in the United Kingdom. The UK ensures that not only is every death reported, but they also compile the deaths and reasons for them in a report every three years. This report is available to the public and the locations and names of the deaths remain confidential. This allows the nation and the nation’s health workers to look at the issues without fear of litigation – meaning they have no reason to hide maternal deaths.

To provide some perspective, here are the rates of some other countries:

Australia: 7/100,000

Brazil: 56/100,000

Denmark: 12/100,000

Germany: 7/100,000

Israel: 7/100,000

Japan: 5/100,000

Netherlands: 6/100,000 – note that about 30% of all births here are at home.

United Kingdom: 12/100,000

As you can see, we are rather behind many other countries – and don’t worry, I am going to come back to Brazil and why I included that statistic which is very high for an industrialized country (as is the USA’s number).

Why Are Mothers Dying?

This question is hard to answer since as mentioned above the reporting methods are varied and not always followed. We do know that some deaths are simply not preventable, this is just a fact of life. However, looking at the much lower numbers in other comparable nations we know that unpreventable deaths are not the reason for the very high numbers in the United States.

We know that it is not from lack of care in general – reports show that over 99% of all women in the United States receive prenatal care. However, we have to look at the level of care women are receiving. We have to ask, does a 5 minute rushed visit with your actual doctor count as adequate care? Does more diagnostic testing equal better care? Does spending more money equal quality care? (The numbers say no – we spend more than any other country in the world on birth).

We see a HUGE disparity in death rates in regards to ethnicity. An African-American woman is 3.3 times more likely to die in childbirth than a white woman. This is simply not acceptable in a country as advanced as ours, and one that is supposedly equal. Midwives such as Jennie Joseph are helping to implement ways to combat this disparity – her creation of The JJ Way is an example of how we can work to correct this travesty.

A big question that needs to be asked in the United States has to do with who is providing this care – care that is obviously not saving as many mothers as it should. In the United States women overwhelmingly see Obstetricians. While Obstetricians are amazing for complicated and high-risk pregnancies, they don’t have much training in plain old boring pregnancy and birth.

A majority of the time pregnancy will proceed in a normal fashion, and birth will follow in the normal fashion. When we use care providers who are trained to search for problems there tends to be a trend of finding problems whether they exist or not, or whether they are actually emergencies or not. As the saying goes, “Give a boy a hammer and he will find something which needs to be hammered.”

We can see that in countries were the majority of care is given by midwives (or that country’s equivalent care provider) the maternal mortality rate is lower (and the infant mortality rate is lower as well). The United Kingdom is a great example of this. They are comparable to us in many ways (general health and population structure), and yet consistently have better maternal outcomes. And they use the midwife model of care in which all women start with midwives and only transfer if problems arise. (Note that a woman can opt for an OB to start with, however most do not).

Now for the elephant in the room: the United States cesarean rate. Our current cesarean rate is 32.8% (CDC). Yes – basically 1/3 of all babies in the US are born through cesarean. So are 1/3 of all US women somehow “broken”? Unable to birth? Producing massive or stubborn babies? NO – of course not. If 1/3 of all women in the US were “broken” then those numbers would be reflected all over the world, and the statistics show this is not the case. In the same vein, we are not producing massive babies either – in fact the average birth weight has gone down as the cesarean rates have gone up (and is independent of that rise or that of induction).

Remember when I said I would come back to why I included Brazil? Brazil has a rather good medical system and is considered a developed country, so why the massive maternal death rate (56/100,000)? Take a look at their cesarean rate – 52.3%. Yes – over 50%. Brazil is an interesting case since most of these surgeries are elective, even for the first time mothers. The fear of childbirth is so deeply engrained in Brazilian culture that women jump at the opportunity to have a cesarean and avoid labor totally. A vaginal birth is seen, culturally, as something only poor women do because they can not afford a cesarean.

That mortality rate could be the United States’ future. We see a fear of birth in the US, and a huge cultural love of telling horror stories about labor and birth. We see more interest in elective cesareans (though elective first time cesareans are not significantly altering the rates). As VBACs are “allowed” in fewer and fewer places and malpractice issues continue to rise we see more and more women forced into surgeries they do not want or need. Our rates are heading right up to that of Brazil’s, and our maternal mortality rates will be sure to follow. A Cesarean increases the risk of death significantly in comparison to vaginal birth.

In comparison, the rate of cesarean in the UK is 25%, the Netherlands has a rate of 14%. As I stated before, the UK has 12/100,000 rate and the Netherlands 6/100,000 – rather interesting that as the rate of cesarean is almost half in the Netherlands and their rate of maternal death is also half that of the UK. While in some countries a higher cesarean rate does not correlate to a significantly higher mortality rate, those countries with very high rates of cesarean typically have higher (or rising) mortality rates.

We also cannot forget postnatal care. The postpartum period is one that needs care just as much as the prenatal time period. In the US, typically a woman is seen in the day or two after birth, at two weeks or so, and then at six weeks…and that is about it. This is simply not enough during this time of life when hormones are changing, the body is attempting to heal from creating another life, and things like retained placenta or clots can cause major issues. A much better plan of postpartum care must be put in place.

What Can We Do?

Be Educated. That is the number one thing you can do to not only help yourself have a safe pregnancy and birth, but also to help the women around you as well. When you learn, share the information. Break down the myths that pervade this culture – break down the assumption that VBACs are dangerous, or that “big babies” need surgical birth. Share the studies and articles you read.

Be Fearless. Help to eradicate fear of birth. Can birth end in tragedy? Yes. Unfortunately is does happen. But with proper and evidence-based care we give ourselves and our babies the best chance. Share the positive birth stories you hear. Share your positive birth. How does this help? It helps women to not fall into a fear based decision that increases her risks of complications – namely induction and cesarean. When a woman can start her pregnancy and birth journey from a positive place it gives her more space for growth and research. Absence of fear is not ignorance of risks – it is not being beholden to the fear of risk.

Those two things hand-in-hand – education and fearlessness – can go a long way towards helping this mortality rate go down. An educated woman is better able to avoid situations or care providers that increase her risks, and a fearless woman is better able to stand up for herself and decipher what is really in need of intervention and what is not without cultural fears clouding her view. Lets do our part to save mothers.

I think your forgetting a third thing which is be healthy. Women who maintain good health prior to pregnancy are more likely to have uncomplicated pregnancies and births. Women who could not get pregnant 100 years ago now have access to fertility medications etc which is great, but we now have a higher risk population that we are serving. I hope that we can reduce the csection rate, it’s due time, but we also need to prepare ourselves for healthy pregnancies!

Sadly in America, birth is seen by many doctors as a way to make a lot of money and the way for them to make the most money is by performing a cesarean. There’s a fantastic article that I read a while ago that was written by an obstetrician that explains exactly this: http://www.glorialemay.com/blog/?p=844

Also, I am not a fan of the medical model because most of them (yes, not all) seem to think that baby needs to be born by a certain timeline and if the baby is taking their time to come, many medical personnel seem to think that they need to hurry things along, thus medical intervention. I love that midwives work with the mother and do what is best for mother and baby. Sadly, this is not the case with many obstetricians. Before I transferred to my midwife (I was on a waiting list), I was seeing a doctor and in the two 15 minute appointments that I had with her (before happily transferring to a midwife), the doctor showed little interest in me and actually brushed off my concerns and said that they were unfounded (which I found out later from my midwife AND specialist post birth that I was actually correct in my concerns and was bang on with what I had read about my symptoms.)

We live in a society that thinks that the medical model is best, when clearly statistics are showing the opposite. And understand that some women with medical complications need to have an obstetrician for their childbirth, but most women do not and could probably avoid a cesarean altogether.

I used a birthing stool when I gave birth to my daughter and within minutes she came out, no problems. I know that some women will still have complications, but I firmly believe that if we went back to nature and gave birth using gravity, rather than fighting against it, there would be so many less complications in birth.

It is a sad thing that no one ever talks about because everyone feels we should be happy. It is very important to know why pregnant women die during their pregnancy. There are MANY different assumptions as to why it happens, it’s just not clear enough.

I thought of some here below that could be a cause, but, it is not certain:

*depression
*relationship issues
*stress (in amounts that a person may not be able to handle)
*worry about the future and the outcome
*their environment they are living in
*physical and mental abuse
*mental issues
*lack of help from others (family, friends)
*worry about financial status

…and there are probably many other combinations of reasons as well. This is what I have come up with so far. I pray that every mother gets the chance to experience a love that is so special. I have 5 children and I have my last one on the way very soon. I feel that it is important for any women to be respected and treated with all of the love, support and guidance they need to feel welcomed as a new mom, veteran mom and as a pregnant women. I now have 2.5 weeks left and I am eager to hold our new addition to our family in our arms.

This was very informative. I am currently 37 weeks pregnant with my first and I opted for an OBGYN because I thought that they were much more informed and knowledgeable about babies & birth then were midwives. I had the idea that a midwife was more of a doula than anything. I have had the same experience with an OB as most. My appointments though scheduled to be 20 minutes long (still a short appointment but still) I am only see for a maximum of 10 minutes!! The last one was to check to see if my son was head down. The did a quick ultrasound, saw he was and called it good and sent me on my way. No measuring him. No seeing if anything has arisen in the almost 20 weeks since his last ultrasound nothing. I am very disappointed in how I have been cared for. In the beginning they considered my pregnancy higher risk because I have had miscarriages and was seeing a fertility Dr. because my husband and I were having such a hard time getting pregnant and staying pregnant. But after the 1st trimester ended they just stopped caring. I feel more like a burden than anything and I feel like the OBGYN’s that I see (yes I see multiple as they just pass you around from Dr. to Dr. by who has an appointment open) just do this for the money. I am thinking my next go around with pregnancy, if there is one, I will try a midwife.

Brittany- it’s not too late to switch! I had similar feelings near the end of my first pregnancy and didn’t think I could switch so ate, but I wish I had because I ended up with a completely unnecessary c-section (my Dr had a plane to catch). Now I am a VBAC forever and have to have all sorts of extra appointments and extra monitoring during labor and I can’t birth at a birth center… (I’ve had two VBACs btw).

I would look up your local ICAN Chapter and see if they can help you find a midwife to switch to now, or at least a better OB!

This is a good article, great information. I’ve found it a challenge however, to get other women to listen when it comes to these topics. I had an all natural birth with both of my children, and when I share that they act like I’m some kind of super woman or something, or maybe they think I’m crazy. But they never follow my advice about not being induced, or seeing a midwife or trying to do it naturally. When it comes to c-sections, they all seem to think it won’t happen to them. But four out of my last five pregnant friends were induced, had epidurals and then ended up with a cesarean.
How do you get women to take this seriously?

Great postnatal care is also a big contributor to low maternal mortality rates in the Netherlands. I’m an American expat living in the Netherlands, and after having my first three babies with midwives in a hospital birth center in Rhode Island, I just had my fourth in the Netherlands, a home waterbirth with a midwife.

The standard of care here is for a week of postpartum in-home nursing care largely covered by insurance. I had a trained nurse (experienced in caring for babies and moms and lactation consulting) at home with me for six to eight hours every day for a week after my daughter was born. I literally stayed in bed for the first four days except to go to the bathroom. I have never recovered so quickly from birth!

I am so happy to hear that you have never recovered sooner than in The Netherlands with the ‘kraamverzorgster’/ nurse there all week after a home water birth. I am from The Netherlands as well with four children (first two deliverd in hospital, second two delivered at home with midwife, all the births no medication whatsoever). It’s so easy here to deliver at home and we are one of the safest countries in the world around child birth. I am glad you where here in Holland to experience a home water birth and wish you all the best!